Courage Under Fire

When SARS broke out in Canada last winter, Toronto was the hardest hit city outside of Asia. At great personal cost, health-care workers and officials worked together to contain the outbreak, care for the sick and calm public fears. On the front lines stood many U of T faculty and alumni who not only helped save the day, but continue to push for changes to ensure that the next medical crisis will be handled better.

SARS originated in Guangdong province, in South China, as a strange new respiratory illness most likely passed from exotic animals to humans. Late last February, a doctor who had treated patients with atypical pneumonia in Guangdong travelled to Hong Kong, where he infected at least 12 guests at the Metropole Hotel. One of those guests returned to Toronto, bringing the disease with her. Canada’s first SARS outbreak lasted from March 13 to April 23, 2003; a second outbreak was declared on May 23 and ended on June 30. During the two outbreaks, there were 438 SARS cases in Canada, including 44 deaths.

In the battle against SARS in Toronto, doctors, nurses and public health workers logged countless hours of work. Amid confusion and uncertainty, they overcame their fears by pulling together. But they were not immune: more than 100 health-care workers became ill with SARS, and three died.

Here are the stories of three of U of T’s own who served at the forefront of the crisis.

Meredith Allin Muscat (BScN 1999, MN 2003)
It was the phone call that every Toronto nurse had come to dread. And when Meredith Allin Muscat, a registered nurse at St. Michael’s Hospital, answered the phone late last May, Toronto Public Health was on the other end of the line, ordering her into quarantine for 10 days. “They told me that on one of my clinical placements at another hospital, I’d been in contact with a patient who was now suspected of having SARS,” recalls Allin Muscat, who graduated from U of T’s nursing program in 1999 and recently completed the Master’s of Nursing program and earned her Acute Care Nurse Practitioner certification at the university. “I felt fine, but I knew that if I’d been exposed, I had exposed my husband and friends. Working in the intensive care unit, I’d seen how sick the SARS patients got, and it scared the dickens out of me to think that I might be the cause of somebody I cared about ending up like that.”

Monitoring her temperature, Allin Muscat hunkered down at home for 10 days of isolation. Toronto Public Health instructed her and her husband, Mario, not to share a bed or bathroom or eat within 10 feet of each other. In a two-bedroom apartment, Allin Muscat says it was “absolutely impossible” to adhere to those instructions. So her husband of less than one year had to stay with friends. “He came to visit me for 10 minutes every night and we’d sit across the room from each other wearing our masks. For newlyweds, that’s not the way it’s supposed to be.” Allin Muscat quickly grew bored with watching movies and reorganizing her cupboards. “Being stuck at home was driving me nuts,” she recalls. “I wanted to get back to work, to get back to some kind of normalcy. And as a master’s student, I was worried that I was going to lose my clinical placements.”
When Allin Muscat returned to St. Mike’s with a clean bill of health, she was deeply concerned about working in a hospital environment. “I’d been exposed to SARS when I was doing exactly as I was told to do to protect myself and my patients, so I was scared to go back. I’ve been nursing in intensive care for four years, but I felt like it was my first day.”

In many ways, the hospital environment was a whole new world for health-care workers during the second SARS outbreak. “If it could come back that quickly, we thought it might never leave. And we still weren’t sure how you got SARS or how it spread. We were getting different guidelines for infection control every day.”

To add to the tension, the hospital’s regular pool of nurses was diminished: in an effort to curb the spread of SARS from facility to facility, nurses were restricted from working at multiple hospitals. This directive compounded a problem that nurses had been red-flagging for years. Due to cutbacks and human resource practises, many nurses who wanted to work full-time hours are forced to work on a part-time or casual basis in more than one facility.

During the second SARS outbreak, St. Mike’s was one of only four hospitals designated to care for SARS patients in the Greater Toronto Area, with five isolation rooms in the intensive care unit where Allin Muscat nursed. When caring for a SARS patient, she changed into protective gear at least eight times during her 12-hour shift. Each time, she spent five to 10 minutes to put on two gowns, two pairs of gloves, a cap, a face shield, a mask, goggles and booties before entering a patient’s room – and just as long to disrobe and disinfect when coming out. The gear made it more difficult to care for patients because it impeded communication, says Allin Muscat. “I was exhausted from breathing carbon dioxide in the mask all day,” she adds. “And the elastic band on the mask was so tight that everyone was losing skin on the bridge of their noses and cheekbones and getting headaches.”

Last August, Allin Muscat was finally permitted to shed her protective gear in the ICU. “As soon as they said we were clear of SARS, the masks came off really quickly. People were so relieved that they just went back to the way things were before,” she says. “But if our guard is down, it could happen again.”

“Before the second outbreak started, nurses saw symptoms of SARS in certain patients and tried to draw attention to it, but their opinions were disregarded,” says Allin Muscat. “If this happens again, I hope nurses will be taken seriously, or things could explode again.”

On March 14, Dr. Barbara Yaffe was to attend a family birthday party for her 13-year-old son, Daniel. Instead, the director of communicable disease control and associate medical officer for Toronto Public Health found herself standing behind a microphone fielding questions from reporters.
With Dr. Sheela Basrur (MD 1982, MHSc 1987), the chief medical officer of health, away, Yaffe was Toronto’s acting medical officer of health. A new infectious respiratory illness had killed a second member of a Toronto family, so Yaffe and members of the Ministry of Health and Long-Term Care called an emergency press conference to warn the public.

Yaffe knew that a hotline had to be up and running by the time news of the disease hit the papers. By next morning the story was front-page news, and the first of more than 300,000 calls started flooding in from a concerned public. For the next three-and-a-half months, Yaffe, who is also an assistant professor in the department of public health services in U of T’s Faculty of Medicine, clocked 14-hour workdays, sometimes for seven days a week.

Then, as Yaffe was coping with the emergency of the new disease, her 84-year-old mother, Bella, was admitted to Mount Sinai Hospital with heart problems. For the first week, Yaffe could visit her, but then hospitals banned all visitors to control the spread of SARS. “I’d call her and she’d be crying into the phone because she didn’t understand why I wasn’t coming to visit her,” recalls Yaffe. Difficult as it was, she thought the decision was right at the time. “By Phase 2, we were learning that maybe we didn’t need quite so stringent measures, and that you have to look at the human side as well.”

The need for the physical presence of family and friends during an illness became abundantly clear to Yaffe when her mother was released from hospital two weeks later. “She had really deteriorated in that period with no visitors.” Just days after coming home, Yaffe’s mother died. “I’m thankful she got to be home, but she didn’t get to see me much in the last weeks of her life.”

Prior to her mother’s death, Yaffe and her colleagues at Toronto Public Health – along with the Ministry of Health and Long-Term Care and other health units – had made the call to quarantine people, a measure that hadn’t been taken in more than half a century. By the end of the outbreak, Toronto Public Health had followed up on 23,306 people who had potentially been exposed, and had quarantined as many as 6,995 individuals at any one time. For every person diagnosed with or suspected of having SARS, public health staff had to track down how each individual contracted the disease and all the people that he or she might have infected. It was a massive undertaking, worsened by the city’s antiquated information-recording system. “We had a provincial communicable disease database that was put into place in the late 1980s,” says Yaffe. “I’d been involved in writing a report on the need for investment in new technology for disease control. Unfortunately, the ministry couldn’t get funding.”

For the two weeks before Toronto Public Health’s information-technology section could create a new system, the health officials relied on handwritten records and colour-coded Post-it notes. “It was crazy!” says Yaffe of the colossal effort of the 700 public health employees who worked on SARS containment. “We were date- and time-stamping everything, because things were changing by the hour. There were unbelievable piles of files everywhere and lists on the walls. We needed to follow up with people, but with the paper system there was real potential for gaps and duplication.”

When SARS finally appeared to be contained, Yaffe faced yet another battle: convincing the World Health Organization (WHO) to lift its April 23 warning on travel to Toronto. “At that point, SARS seemed to be under control, and issuing a travel advisory didn’t make sense to us,” she says. On April 28, Yaffe travelled to Geneva with then-Ontario health minister Tony Clement (BA 1983 UC, LLB 1986), Ontario’s chief medical officer of health, Dr. Colin D’Cunha (MHSc 1985), and two Health Canada physicians. Their job was to persuade WHO that Canadian health officials were taking SARS seriously, that there hadn’t been a new SARS case in 20 days – which is double the incubation period – and that hospital staff were performing surveillance. WHO lifted the ban immediately.

Yaffe didn’t have long to celebrate, though. Just three weeks later, she faced her most difficult decision of the SARS crisis, the decision to declare Phase 2. It was tough to assess the information about a small outbreak of respiratory illness with fever at St. John’s Rehabilitation Hospital in Toronto, but elements of the illness suggested that it might be SARS, says Yaffe. “We wanted to make sure that we weren’t over-calling it or under-calling it.”

By chance, Basrur was away again after co-ordinating the city’s response for eight weeks, so once more Yaffe faced the press. This time, the reception was different. “In Phase 1, my feeling from the media was, ‘How can we work with you and help you get the message out on this?’ And in Phase 2, it felt like, ‘Let’s figure out who did what wrong so we can blame them,’” she recalls. During Phase 2, there were 82 SARS cases and 14 deaths among Toronto residents.

For Yaffe, the next couple of months were a whirlwind of a type that she had never experienced in her 20-year career in public health. “I have dealt with big outbreaks, like the cyclospora outbreak in 1998, but this was the most stressful,” she says. “During the worst of SARS, I had my teenage daughter crying and saying ‘You should quit your job!’ She was worried that I was under too much stress.”

No chance of quitting, Yaffe says. But she knows her view of the health-care system will never be the same. “I think we’ve developed better communication with hospitals and between the different levels of government, but there’s still a long way to go.”

Meet other faculty and alumni who helped manage the crisis:

Dr. Sheela Basrur (MD 1982, MHSc 1987), chief medical officer of health, spearheaded Toronto’s efforts to control the outbreak. The U of T professor of public health sciences held daily press conferences to keep the public informed.

Tony Clement (BA 1983 UC, LLB 1986), Ontario’s then-minister of health, announced on March 26 that SARS had been declared a provincial emergency. He named experts to the Walker Panel, to provide advice on infectious-disease control.

Dr. James Young (MD 1974) is Ontario’s chief coroner and commissioner of public safety and security, and an associate professor in U of T’s department of laboratory medicine and pathobiology. He is also responsible for managing the province’s response to emergencies and evaluating what went wrong after a crisis such as SARS.

Dr. Donald Low, chief microbiologist at Mount Sinai Hospital, is a professor in the department of medicine at U of T. He assessed and treated patients as a member of the SARS containment team. Low criticized Health Canada for not updating its definition of SARS, and after he disclosed this concern to the media on May 28, Health Canada reconsidered its definition within 24 hours.

Dr. Peter Singer (MD 1984) is the director of U of T’s Joint Centre for Bioethics, which submitted the report Ethics and SARS: Learning Lessons from the Toronto Experience to the National Advisory Committee on SARS and Public Health.